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Job # 23308
Position Title Case Manager – RN FT Days – 6 positions
Location Houston TX
Compensation $67K – $101K Relocation Assistance Available
Job Description Employer: Major Medical CenterSUMMARY Comprehensively plans for case management of a targeted patient population. Works with the physicians and multidisciplinary care team to facilitate efficient, quality care, and achievement of desired treatment outcomes. Holds joint accountability with social worker for discharge planning and continuity of care. Assures that admission and continued stay are medically necessary and communicates clinical information to payers to ensure reimbursement. DUTIES AND RESPONSIBILITIES 1. PATIENT SCREENING AND ASSESSMENT:
1.1 Uses clinical expertise and high risk screening tools to identify need for case management and/or social work intervention. Screening is accomplished by patient/family interview, review of the medical record including previous episodes of care, H&P, lab and other test results/findings, plans of care, physician orders, nursing and progress notes. 1.2 Completes full assessment based on the case management high risk screening tool. 1.3 Continuously reviews the total picture of the patient for opportunities for care facilitation and needs for discharge planning. 1.4 Applies approved utilization criteria to monitor appropria10ess of admissions, level of care, resource utilization and continued stay. 1.5 Documentation should reflect completed patient screening/assessment and reassessment upon admission and concurrently as needed. This should be documented in MethOD.
2. CARE FACILITATION: 2.1 Coordinates and facilitates patient progression throughout the episode of care. Works collaboratively with members of the healthcare team to effectively facilitate patient management. Promotes plan of care consensus from patient/family, physician and payer 2.2 Proactively identifies and resolves barriers impeding diagnostic or treatment progress and discharge plans. Documents care facilitation actions in Case Management notes in MethOD. 2.3 Initiates timely referrals of issues to the Manager and/or Physician Advisor of Case Management and Social Work Department to elicit assistance to overcome medical management barriers. 2.4 Identifies barriers affecting timely patient management and documents avoidable days/variances in Maxsys II.
3. DISCHARGE PLANNING: 3.1 Discharge needs should be identified and addressed at the time of the first screening/assessment as appropriate. 3.2 Facilitates transition and continuity from the inpatient setting to the next level of care. The process includes assessing the appropriate level of care, formulating the plan, gaining agreement and executing the plan. . Documents plan in the Case Management section in MethOD. 3.3 Facilitates discharge planning activities for assigned patients and collaborates with the social worker and other members of the interdisciplinary team on complex discharges. Maintains ownership of the discharge planning process on assigned units. 3.4 Uses knowledge of levels of care to ensure discharge disposition is to the appropriate level and facilitates transfers. Initiates and facilitates referrals for home health care, hospice, and durable medical equipment. Consults Social Worker to assess psychosocial needs associated with transition to alternative levels of care. 3.5 Seeks assistance from appropriate disciplines/department as needed to expedite care, manage length of stay and facilitate discharge. 3.6 Completes CM/SW Discharge Summary for all patients for whom discharge planning services were provided. Gives a copy of discharge summary to patient prior to discharge.
4. COLLABORATIVE COMMUNICATION: 4.1 Develops effective partnerships with healthcare team members. 4.2 Participates fully in patient care and discharge planning meetings. 4.3 Actively participates in multi-disciplinary communication and team building in department and assigned units. 4.4 Demonstrates ability to communicate and negotiate with all levels of the organization and community with documented information and recommended solutions 4.5 Demonstrates collaboration and teamwork with social worker assigned to their units and with Resource Center. 4.6 Provides information to patient/family and other members of the health care team in a way that is clear, understandable, empathetic and demonstrates ICARE values.
5. UTILIZATION MANAGEMENT / PAYER COMMUNICATION: 5.1 Performs review for medical necessity of admission, continued stay and resource use, appropriate level of care and program compliance using InterQual Hospital Severity of Illness and In10sity of Service Criteria or Milliman Care Guidelines. Standard for initial review is within 24 hours of entry or next working day. Preferred frequency of continued stay review is every 3 days, but may be more or less frequent depending on the severity of illness and the presence or absence of treatment criteria. 5.2 Secures reimbursement for hospital services by communicating medical information required by all external review entities, managed care contracts, insurers, fiscal intermediaries, and state and federal agencies. Responds to requests for information, monitors covered days, and initiates review to assure that all days are covered and reimbursable. 5.3 Manages all patients in Observation Status, informing physicians of timely disposition options to assure maximum benefits for patients and reimbursement for the hospital. 5.4 Denial Management: Identifies when services no longer meet InterQual/Milliman guidelines, initiates discussion with attending physicians, coordinates with the external case manager to facilitate discharge planning, seeks assistance from the physician advisor, if needed, informs supervisor of the possible need for issuing Medicare Hospital Initiated Notice of Non-coverage. 5.5 Fulfills all requirements for timely distribution of Important Message from Medicare. Follows departmental procedures for Medicare discharge appeals. 5.6 Educates physicians, care providers, patient, and families regarding payer plans and benefits.
7. Demonstrates ICARE values.
8. ServicePride Standards
9. Follows all safety rules on the job.
10. Performs other work as assigned and supports department commitment to appropriate staffing of institution.
EDUCATION REQUIREMENTS Bachelor of Science in Nursing (BSN) required (2-3 years recent case management experience). For Skilled Nursing unit, Rehabilitation and Psychiatry case management, BSN or Master of Social Work (MSW) required.
EXPERIENCE REQUIREMENTS 3-5 years clinical experience 2-5 years case management experience preferred. CERTIFICATES,
LICENSES AND REGISTRATIONS REQUIRED Registered Nurse (RN) license in the State of Texas. Master of Social Work (MSW) license in the State of Texas.
SPECIAL KNOWLEDGE, SKILLS AND ABILITIES REQUIRED 1. Critical thinking, advanced communication, negotiation and collaboration skills. 2. Computer skills. 3. Organization/time management and prioritization skills.
NOTE: Must have BSN and experience in acute care


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